To inform residential care workers about their record keeping responsibilities.
Residential care planning includes tasks such as developing residential care plans, care plan reviews, trauma profiles and safety plans in accordance with relevant policies. Once completed these documents must be stored in the child’s residential care objective file.
The Log Book is used to record events occurring within the home. The Log Book is a legal document and must not be used for personal comments and communications.
Log Book entries must:
The case notes are used to record all relevant information about each individual resident. They should reflect the child’s residential care plan and safety plan.
Case notes must be completed towards the end of every shift. Case notes should be as detailed as possible, while remaining objective. When completed, case notes must to the child’s residential care Objective file.
All other relevant documentation relating to a child’s care received by the residential care workers should be sent to case managers to be stored appropriately.
All appointments must be recorded in the home’s diary.
Diary entries should state all relevant information clearly (who, who with, who organised it, where, when, how getting there, how getting back, when due back, does it need confirming).
All weekly team meeting minutes should be recorded and include the following information: date, time, attendance, relevant children and operational information.
Minutes should be saved on the appropriate Objective file and made available to all residential care workers.
Important medical information is discussed and recorded when a child is placed in the home. Discussion must include information about medical alerts, medication and any other health concerns.
Medication Charts must be completed before any medication is administered to the child. Residential care workers must sign this form stating that the medication was offered and taken. Alternatively, a refusal should be recorded as such.
Each child’s Medication Chart must be scanned into his or her Residential Care Objective file regularly.
For more information refer to 6.6 Health and Medication.